Professional SkillsUrology Core Module

Trustin Domes

Outline

• Brief Anatomy of Scrotum and Prostate• Physical Examination: CVA, Scrotum and DRE• Case Scenarios– LUTS– Hematuria– Upper and lower urinary tract obstruction– Scrotal Masses/Pain

Anatomy of Scrotal Contents• Vessels:– Testicle has 3 arterial blood

supplies:• Testicular artery• Cremasteric artery• Deferential artery

– Pampiniform venous plexus• Lymphatics• Nerves• Cremasteric muscle/fascia• Vas deferens

Anatomy of Scrotal Contents

• Vas is the most posterior component of spermatic cord

• Tunica vaginalis surrounds the anterior 2/3rd of the testicle and creates a potential space for hydroceles and hematoceles

Clinical Anatomy of the Prostate

Verma S , Rajesh A AJR 2011;196:S1-S10

Prostate Anatomy

• Peripheral Zone = 85% of prostate cancer originate in this zone, therefore are detected on DRE

• Transition Zone = site of benign prostatic hyperplasia

CVA and BallottementIf CVA tenderness think:- Renal colic- Pyelonephritis- Significant renal trauma- Renal vascular occlusion

If you can ballot the kidney think:- Large renal mass- Polycystic kidney disease- Severely hydronephrotic kidney

Physical Examination of the Scrotum• Best to examine the man in both the supine and

upright positions– Helps to demonstrate conditions that change with

position: hernias and varicoceles• Bimanual examination of each testicle, adenxa and

spermatic cord– Testicular size, consistency, masses, tenderness• Normal testis size 16-20 cc (2 x 4 cm)

– Examine cord upright (+/- valsalva) to assess for presence of vas deferens, inguinal hernia and varicocele

Cremasteric Reflex

• Reflex elicited by stroking the medial thigh causes an ipsilateral contraction of the cremasteric muscle (bringing the testicle closer to the external inguinal ring)

• Reflex tests L1-L2 (genitofemoral nerve responsible for afferent and efferent limbs)

• Typically absent in testicular torsion– Negative predictive value of over 90%

Transillumination• Important to help

differentiate solid from fluid-filled masses

• Hydroceles and spermatoceles will transilluminate, other scrotal masses typically WILL NOT

Hydrocele

Varicoceles• Dilated veins of the paminiform plexus• Predominant left-sided (98%)• Isolated right-sided varicocele may be

caused by a retroperitoneal– NEED abdominal imaging

• Varicocele grading:– Grade I: palpable only with valsalva– Grade II: easily palpable without

valsalva– Grade III: large, visible through

scrotal skinGrade III: “bag of worms”

Digital Rectal Examination

Comment on:• Prostate

• Size• Symmetry• Consistency• Tenderness• Nodules

• Rectal/Anal Masses• Rectal Tone

Prostate size

25 cc 150 cc

Average prostate size is approximately 25 cc in menolder than 50 years

How many finger-breadths across?Can you get to the top (base)?